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Systemic Viral Infection
A Case Study Presented the
Faculty of the College of Nursing
Of University of Saint La Salle
Bacolod City
In Partial Fulfillment
Of the Requirements for the
Degree in Bachelor of
Science of Nursing
Submitted by:
Karin Agramon
BSN 3K
August 23, 2010
1
Table of Contents
Title page 1
Table of Contents 2
Introduction 3
Objectives 4
Anatomy and Physiology 5
Definition of Terms 11
Baseline Data 12
Physical Assessment 13
Nursing History
Gordon’s Functional Pattern 14
Health History 18
Laboratory and Radiology 20
Nursing Care Plan
Risk for Infection 25
Tissue Perfusion 26
Hyperthermia 27
Drug Study
Omepron 28
Ambroxol 29
Health Teaching 30
References 31
2
I. INTRODUCTION
Infection is the invasion and multiplication of microorganisms in or on body tissues that
cause signs, symptoms, and an immune response. Such reproduction injuries the host by causing
cell damage from toxins produced by the microorganisms or from intracellular multiplication or
by competing with host metabolism. Infectious diseases ranges from relatively mild illnesses to
debilitating and lethal conditions: from the common cold through chronic hepatitis to acquired
immunodeficiency syndrome. The severity of the infection varies with the pathogencicity and
number of invading microorganisms and the strength of host defenses.
For infection to be transmitted, these factors must be present: causative agent, infectious
reservoir with a portal of exit, mode of transmission, a portal of entry into the host, and a
susceptible host.
As for the Systemic Viral Infection it is an Infection where in all systems are susceptible to
kinds of microorganism in a way that the entire organs contribute to each other to be infected.
I chose this case because of the fact that having this kind of disease is very much dangerous
in terms of its effects. We can get a lot of ideas on how we can prevent complications that may
alter our normal conditions, considering that we are prone to it because we are in a tropical
country and we can easily acquire diseases because of the fact that we Filipinos are very
hospitable enough that we can’t say no in helping a person even we know that he or she is a
carrier of a contagious disease.
The significance of conducting this study is that knowing the disease and its underlying
causes will serve as a basis for the plan of care in which will cater comfort and improvement of
the client. The goals of care are mostly directed to the client who will be presented in this study.
This study hopes to answer the questions about Systemic Viral Infection; what is it and how it
affects the lives of ordinary people.
3
II.OBJECTIVES
General Objectives
After 40 hours of nurse-client intervention, the student nurse
will be able to:
1. Identify the nature of SVI.
2. Determine the process involved in having this kind of disease.
3. Discuss the appropriate nursing interventions in the management of
SVI.
Specific Objectives
After 40 hours of nurse-client interactions, the student nurse
will be able to:
1. Discuss the nature, causes, signs and symptoms, treatment and
diagnostic procedures of the disease.
2. Determine the deviations on laboratory tests and its significance to the
disease.
3. Illustrate the pathophysiology of SVI.
4. Formulate a nursing care plan which addresses the specific needs of
the client.
5. Perform through drug study on medications prescribed to client with
SVI.
6. Conduct health teaching regarding client’s condition.
4
III. ANATOMY and PHYSIOLOGY
5
6
7
8
9
IV. DEFINITION of TERMS
Circulation – the movement of blood, through the vessels of the body caused by the pumping of
the heart
Circulatory System – system of blood, blood vessels and lymphatics and heart concerning the
circulation of the blood and lymph
Corpuscles – a minute particle, a living cell. One red blood cell or one white blood cell.
Platelets – one of the minute discs of vertebrate blood clot that assists in blood clotting.
Acute Infection – short duration of the order of several days.
Chronic Infection – long duration of the order of weeks or months.
Systemic infection – the infection is widespread throughout the body and must be assumed to be
in all organs.
10
V. BASELINE DATA
Name: Patient N.Y.
Address: B8, Lt2, Jesusa, Estefania, Bacolod City
Birth Date: January 6, 1993
Birth Place: Japan
Age: 17 years old
Gender: Female
No. of Dependants: none
Marital Status: Single
Religion: Christian
Educational Level: Secondary Level
Nationality: Filipino
Occupation: Student
Person next to kin: Mother
Admission Date: August 16, 2010
Attending Physician: Dr. Joaquin Moreño, MD
Chief Complaint: fever and cough
Diagnosis: Systemic Viral Infection
Date of Surgery: not applicable
11
VI. PHYSICAL ASSESSMENT
CEPHALO-CUADAL APPROACH
LOC:
On bed, Awake
Responsive to both verbal and non-
verbal stimuli.
Oriented to time, place, date, and
person
HEENT:
Pupil Equally Round Reactive to
Light and Accommodation.
With pale conjunctiva
With anecteric sclera
Without nasal discharges
Hearing Intact. Landmarks visible;
no bleeding or drainage
CARDIOVASCULAR:
With IVF # 5 D5LR x 125 cc/hr @ L
metacarpal vein with a remaining
solution of 480 cc.
With poor capillary refill longer than
3 seconds.
With BP of 90/60 mmHg; taken @ R
arm in sitting position.
With Pulse rate of 80 bpm; taken @
R radial pulse.
RESPIRATORY:
Breathes spontaneously to room air.
With RR of 25cpm.
GASTROINTESTINAL:
On DAT; with poor appetite.
GENITOURINARY:
Not able to defecate upon
assessment.
Able to urinate without assistance @
approximately 250 cc
MUSCULOSKELETAL:
Able to perform both active and
passive ROM.
Able to ambulate without assistance.
INTEGUMENTARY:
With good skin turgor.
Mucous Membrane not noted.
With pale color r/t race of father
(JAPANESE).
With dry skin, and warm to touch.
With Temperature of 38.6
12
VII. PATHOPHYSIOLOGY
Precipitating Factors Predisposing Factors
Age: 17 years old Emotional and Physical Hematologic State: Stressors
↓ RBC Poor appetite↓ WBC not eating balance diet↓ HgB and Hct↓ Platelet count
Immunocompromised
Pathogen replicates, thus duration of disease occur and range from instantaneous years.
Inflammation occurs as a major reactive defense mechanism in the battle against infective agents
Arterioles at or near the site WBC’s and platelet move towardOf the injury briefly constrict and thus dilate, the damaged cells.Thus ↑ in fluid pressure in capillaries. At the same time inflammatory cells release histamineAnd Bradykinin w/c further ↑ capillary permeability.
RBC’s and fluid into the interstitial space, Phagocytosis of dead cells and Contributing to edema. Microorganisms begin.
↓ of platelet count is seen during CBC,
Together with the RBC, Hgb, Hct, and the rest of the hematological count in the test.
Signs and Symptoms
A. FeverB. CoughC. Abdominal painD. HeadacheE. Joint painsF. Sleeping disturbancesG. ConstipationH. Hematoma in upper extremities
VIII. Nursing History (Gordon’s Functional Health Pattern)
13
A. Health Maintenance – Perception Pattern
Patient is aware of her condition. She perceived health is very important
especially to her as a student. She claimed of having Systemic Viral Infection and very
optimistic towards her condition. She consulted her Pedia on the moment she suspected
of the symptoms of her illness. She is a non-smoker as well as non-drinker. Patient also
stated that she does not have any OTC drug or food allergy.
B. Nutrition – Metabolic Pattern
Client is not wearing dentures in both upper and lower teeth. Her usual diet is
more in chicken and pork. She ate trice a day with snack between it, but she has a poor
appetite. She has no difficulty in swallowing, thus she is independent in eating and
drinking. She stated that she doesn’t drink very often fluids. She also stated that every
time she had wounds, the healing pattern of such is very fast especially if it is just a
normal scratch.
C. Elimination Pattern
Patient can void freely at home within normal frequency at the normal pattern
three times a day with approximately 240cc/urination. She can defecate twice in a week
, but sometimes she has difficulty in eliminating it.
D. Activity and Exercise Pattern
Patient is studying. Her activities include walking, bathing, and dancing as a part
of her extra-curricular activities in school. She stated that she is exercising every
morning as a part of her daily routine.
E. Sleep and Rest Pattern
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Patient usually sleeps eight hours at night and sometimes less than her usual
pattern. She stated that sometimes she sleeps late at night because she needs to study
her lesson for the next day or finish her assignments and projects as a part of her
requirements in her respective subjects.
F. Cognitive Perception Pattern
Patient is on the Formal Operational Stage of Jean Piaget’s Cognitive
Development. She answers all my questions without any sensory deficit. She is good in
logical thinking as well as in reasoning and conceptualization. She also can deal
hypothetical situations, and questions. Right now she is currently enrolled in high
school here in Bacolod city as a second year high school student. She doesn’t have any
disease that can affect her mental or sensory functions.
G. Self-Perception Self-Concept Pattern
Client was able to view her life in a positive way. She is very comfortable in her
appearance, she is grateful to have her body as graceful as others even if she is in the
hospital. She is very confident in dealing with other people. She said that sometimes
she is affected in some of the problems of her friends and family members that’s why
she is not use to just look but she is helping her friends or family members to find a
solution in the problem, that’s why she felt so stress.
H. Role and Relationship Pattern
Patient is on the Adolescence Stage of Erik Erikson’s Psychosocial Development.
She stands as the only child in the family, and a friend. She is open to her friends
especially when it is all about her family. She says that her friends are more likely
important at this stage of her life because she doesn’t want to be lonely at school.
Currently she have her boyfriend at her side and her mom, she said that whatever she
does or whoever she chose she knows that her mother and father will support her and
15
understands her. She doesn’t have any problem in socialization, in communication and
in her family and friends.
I. Sexuality and Reproductive Pattern
Patient is on the Genital Stage of Sigmund Freud’s Psychosexual Stage. She currently
has a boyfriend, and they have good relationship with one another. As a student and a
daughter she sees herself a mother in the future but not in this time. She said that she
will first focus in her studies. She also said that she knows her limitation as a lady. She
does not want to be a burden of her mother. Patient doesn’t have any problem regarding
her reproductive system. Her menarche started at the age of 14 years old, and stated that
she could consume 3-5 pads a day.
J. Coping Stress Pattern
Client said that she copes with her problem through crying and sharing it to her
friends; she also added that she experienced to have a counseling session to their
Guidance Councilor in their school. She said that those practices of her were a very
great help to her in accepting her problem and to learn from it. She don’t drink any
medicines just to be kept calmed, she can manage her problems, and stress without any
of those. She said that she is accepting the major changes that happened and will be
happening to her.
K. Values and Belief Pattern
As a child she had encountered a lot of mistakes, failure, and success. Being
Responsible in all her actions is one of the greatest values she have learned. She also
believed in the saying, “NO MAN IS AN ISLAND.”
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IX. HEALTH HISTORY
1. History of Present Illness
Two days prior ---- patient had sudden onset of high fever (39.5ᵒc).
Non-produsctive cough and nasal catarch.
Fever was lysed with Paracetamol
One day prior ----- persistence of above signs and symptoms on the day of consult.
(-) chills, (-) vowel movement changes, (+) loss of appetite
1. Past Health History
A. Childhood Illnesses
The patient claims to have a normal state of health. She rarely experienced
childhood illnesses like fever, flu, cough and colds. She also said that she doesn’t
have any food or drug allergy.
B. Past Hospitalization
She said it was her first time to be admitted in the hospital. She hasn’t
encountered some serious illness or diseases that could lead her to the hospital.
C. Previous surgery
Patient N has never gone into surgery.
2. Family and Social History
Upon Assessment, patient claimed that her DAD is hypertensive and her MOM is
anemic. She doesn’t know about her family’s health history. She is not sure if her
relatives have illnesses that can be genetically acquired.
3. Psychosocial History
a. Social Habits
- The patient is currently employed as a government teacher. She is a non-smoker,
non-alcoholic beverage drinker and non-user of illicit drugs.
b. Sleeping patterns
17
- She has lots of time to sleep especially if she doesn’t have any homework to do.
She wakes up early in the morning to prepare herself to go to school. She’s not
used to take naps in the afternoon taking into consideration that she is in school
and have a class.
c. Dietary Patterns
- She usually ate three times a day. Her usual meal is composed of rice, pork and
chicken. She claimed to drink 3-5 glasses of water per day.
4. OB-Gyne History
- Her menarche started at the age of 14. And claimed to have an irregular
menstrual cycle. She also said that she can consumed 3-5 pads per day.
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X. Laboratory and Radiology
A. CLINICAL MICROSCOPY SECTION
August 16, 2010
Patient Name: N.Y Date Requested: August 16, 2010
Urinalysis (routine)
Physical Examination Microscopic ExamColor: Straw RBC: 0-1/hpfCharacter: Slightly Turb. Pus Cells: 1-4/hpfReaction: 6.5 Epithelial Cells: MANYSpecific gravity: 1.015 Renal: occasional Mucus Threads: occasional Bacteria: Few
Chemical Exam CastAlbumin: Negative Hyaline: /lpfSugar : Negative Fine Gran: /lpf Course Gran: /lpf Others:
CrystalUric Acid: Urates: FewCalcium Oxalate: Amor Phosphate: Triple Phosphate:
IMPLICATION:
19
B. SPECIMEN: BLOOD
August 16, 2010
Patient Name: N.Y. Date Requested: August 16,2010
Specimen: BloodEXAM Result Normal Values Result Normal Values (S.I.) (C.U.)Sodium 137.00 137-146 mmol/L 137.00 137-145 mEq/dLPotassium 4.43 3.6-5.1 mmol/L 4.43 3.6-5.1 mEq/dLRBS (Random 4.89 4.4-7.7 88.89 80-140 mg/dLBlood Sampling)Creatinine 54.81 53.0-114.92 mmol/L 0.62 0.6-1.3 mg/dL
IMPLICATIONS:
C. HEMATOLOGY
Laboratory/ Diagnostic test
Result Normal Values Interpretation Implication
CBC(COMPLETE BLOOD COUNT)
Hemoglobin 115 g/L 120.00-170.00 g/L
Below Normal Standard evaluation test before surgery
Hematocrit 0.33 0.38-0.47 Below Normal Indicates dehydration
RBC count 3.52 4.60-6.00 x 10^12/L
Below Normal Indicates anemia
Coagulation Profile
Platelet count 126 /L150.00-400 x
10^9/L Below Normal Immunocompromised
WBC 2.2 /L5.00-10.00 x
10^9/L Below Normal Infection
Differential Values
Segmenter 0.70 0.50-0.70 Normal Normal
Eosinophils 0.04 0.00-0.05 Normal No Parasitic Infection
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Monocyte 0.03 0.00-0.07 Normal Normal
Lymphocyte 0.23 0.20-0.40 Normal No Chronic Infection
Remarks:
NORMOCYTIC, NORMOCHRONIC RBC
D. HEMATOLGY
August 17, 2010
Laboratory/ Diagnostic test
Result Normal Values Interpretation Implication
CBC(COMPLETE BLOOD COUNT)
Hemoglobin 109 g/L 120.00-170.00g/L
Below NormalStandard evaluation test before surgery
Hematocrit 0.32 0.38-0.47 Below NormalIndicates
dehydration
RBC count 3.34 4.00-5.50 x 10^12/L
Below Normal Indicates anemia
Coagulation Profile
Platelet count 99 150-400 Below Normal Immunocompromised
WBC 1.2 5.00-12.00 x 10^9/L
Below Normal Infection
Differential Values
Segmenter 0.65 0.50-0.70 Normal Normal
Eosinophils 0.03 0.00-0.05 Normal No Parasitic Infection
Lymphocyte 0.32 0.20-0.40 Normal No Chronic Infection
Remarks:
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E. HEMATOLOGY
AUGUST 17, 2010
Laboratory/ Diagnostic test
Result Normal Values Interpretation Implication
CBC(COMPLETE BLOOD COUNT)
Hemoglobin 105 g/L 120.00-170.00
g/L Below NormalStandard evaluation test before surgery
Hematocrit 0.32 0.38-0.47 Below Normal Indicates dehydration
RBC count3.34
4.60-6.00 x 10^12/L
Below Normal Indicates anemia
Coagulation Profile
Platelet count 87 /L 150.00-400 x 10^9/L Below Normal Immunocompromised
WBC 1.4 /L 5.00-10.00 x 10^9/L
Below Normal Infection
Differential Values
Segmenter 0.52 0.50-0.70 Normal Normal
Eosinophils 0.02 0.00-0.05 Normal No Parasitic Infection
Lymphocyte 0.46 0.20-0.40 NormalNo Chronic Infection
F. HEMATOLOGY
PLATELET COUNT AUGUST 18, 2010
Laboratory/ Diagnostic test
Result Normal Values Interpretation Implication
Platelet count87 /L 150.00-400 x
10^9/L Below Normal Immunocompromised
G. RADIOLOGICAL REPORT
CHEST X-RAY AUGUST 16, 2010
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Name: N.Y
Examination: Chest PA
Result: Chest PA shows no gross lung infiltrates heart is not enlarged. Diaphragm and costophrenic sulci are intact. No other remarkable findings of note.Remarks: Essentially normal chest findings.
H. HEMATOLOGY
PLATELET COUNT AUGUST 19, 2010
Laboratory/ Diagnostic test
Result Normal Values Interpretation Implication
Platelet count 69 /L150.00-400 x
10^9/L Below Normal Immunocompromised
I. HEMATOLOGY
PLATELET COUNT AUGUST 20, 2010
Laboratory/ Diagnostic test
Result Normal Values Interpretation Implication
Platelet count 64 /L150.00-400 x
10^9/L Below Normal Immunocompromised
23
Name of Patient: patient N.K Age: 17 years old Sex: Female Status: SingleMedical Diagnosis:
Assessment Nursing Diagnosis Rationale Desired Outcome Nursing Interventions Justification Evaluation
Actual/ abnormal cues:
RISK FACTORS: ↓ HgB ↓ Platelet
Count ↓ RBC and
WBC Insufficient
knowledge to avoid exposure to pathogens.
STRENGTH: Good family
support. Good financial
support Strong faith in
GOD.
Risk for infection r/t inadequate secondary defenses.
DEFINITION: At increased risk for being invaded by pathogenic organisms.
Source:Doenges, M., et al.Nursing Care Plans Guidelines for individualizing Patient care 6th ed. (2002).Davis Company.Thailand.
Predisposing Precipitating - 17 yrs old - environmental -hematologic stressors State such as: - emotional ↓Hgb, Hct, and physical RBC, WBC, stress And platelet - poor appetite Count.
Inflammation occurs as a major mechanism defense.
Pathogens enter the system, and battle against infection occurs.
Decrease of WBC, RBC, HgB, Hct, and platelet count in the
hematological report.
Hospitalization
Risk for Infection
Source: Medical Surgical Nursing
After 40 hours of nurse-client intervention the client will be able to:
1. Identify interventions to reduce the risk of infection.
2. Verbalized understanding of individual risk factors.
3. Identify techniques, and lifestyle changes to promote safe environment.
INDEPENDENT1. Monitor vital
signs especially the temperature.
2. Asses and document skin conditions with or without insertions.
COLLABORATIVE:1. Stress proper
hand washing techniques by all caregivers between therapies/clients.
2. Encourage early ambulation.
- Fever signifies inflammation thus infection occurs.
- To prevent inflammation on skin surfaces.
- A first line defense against cross contamination.
- For mobilization of respiratory secretions.
After 40 hours of nurse-client relationship the client
1. Goal met. The patient was able to identify interventions to prevent her from infection.
2. Goal met. She was able to verbalize the risk for infection especially with her conditions.
3. Goal met. Patient was able to identify techniques, etc. to promote safe environment such as proper waste disposal.
XI. NURSING CARE PLAN
24
Name of Patient: Age: Sex: Status:Medical Diagnosis
Assessment Nursing Diagnosis Rationale Desired Outcome Nursing Interventions Justification Evaluation
Actual/ Abnormal Cues:
4 napkin pads in 8 hours shift.
Napkin fully soaked with blood.
Capillary refill longer than 3 seconds
Skin temperature changes; TR- 38.6
Risk Factors:
Strengths:
Good financial support.
Good Family Support.
Strong believes in GOD.
Ineffective tissue perfusion r/t decreased in HgB concentration in blood aeb restlessness, and fatigue.
DEFINITION:Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level.
Source:Doenges, M., et al.Nursing Care Plans Guidelines for individualizing Patient care 6th ed. (2002).Davis Company.Thailand.
Predisposing Precipitating - 17 yrs old - environmental -hematologic stressors State such as: - emotional ↓Hgb, Hct, and physical RBC, WBC, stress And platelet - poor appetite Count.
Inflammation occurs as a major mechanism defense.
Pathogens enter the system, and battle against infection occurs.
Decrease of WBC, RBC, HgB, Hct, and platelet count in the hematological report.
Stress in the myometrium
Heavy bleeding during menstrual cycle
Hospitalization
Ineffective Tissue Perfusion
Source: Medical Surgical Nursing
After 40 hours of nurse-client relationship the client will be able to:
1. Verbalized understanding of condition, therapy regimen, and side effects of medications.
2. Demonstrate behaviors/lifestyle changes to improve circulation.
3. Demonstrate increased perfusion as individually appropriate.
INDEPENDENT:1. Identify
changes r/t systemic and peripheral alterations in circulation.
2. Evaluate for signs of infection especially when immune system is compromised.
3. Note customary baseline data.
4. Encourage early ambulation
COLLABORATIVE:1. Administered
medications with caution.
- Changes in both can be a sign of tissue damaged or infection.
- To be given the right way of care and proper medication.
- Provides comparison with current findings.
- Promotes venous return.
- Drug response may be altered any decreased tissue perfusion.
X.NURSING CARE PLAN
25
Name of Patient: Age: Sex: Status:Medical Diagnosis
Assessment Nursing Diagnosis Rationale Desired Outcome Nursing Interventions Justification Evaluation
Actual/ Abnormal Cues:
Headache as patient verbalized
Skin warm to touch
Increase in body temp above normal range TR=39.4
Risk Factors:
Strengths: Good financial
support. Good Family
Support.Strong believes in GOD.
Hyperthermia r/t inability to perspire aeb skin warm to touch.
DEFINITION:Body temperature elevated above normalRange. Source:Doenges, M., et al.Nursing Care Plans Guidelines for individualizing Patient care 6th ed. (2002).Davis Company.Thailand.
Predisposing Precipitating - 17 yrs old - environmental -hematologic stressors State such as: - emotional ↓Hgb, Hct, and physical RBC, WBC, stress And platelet - poor appetite Count.
Inflammation occurs as a major mechanism defense.
Pathogens enter the system, and battle against infection occurs.
Decrease of WBC, RBC, HgB, Hct, and platelet count in the hematological report.
Hospitalization
Chills, inability to perspire, headache, fatigue
Hyperthermia
Source: Medical Surgical Nursing
After 8 hours of nurse-client relationship the client will be able to:
1. Maintain core temperature within normal range.
2. Demonstrate behaviors to monitor and promote normothermia
INDEPENDENT:1. monitor
respirations.
2. monitor intake and output.
3. Monitor laboratory results.
COLLABORATIVE:1. Administered
antipyretics, orally.
2. Provide high caloric diet.
- Hyperventilation may initially present, but ventilator effort may eventually be important by hematologic state.
- To replace GI losses if there is.
- To note if there is a change in any electrolytes and other enzymes.
- To have normothermia.
- To meet increased metabolic demands.
After 8 hours of nurse-client intervention the client was able to:
1. Goal met. Patient was able to normalize and maintain the temperature in normal range.
2. Goal met. She was able to demonstrate behaviors to promote normothermia such as Tepid Sponge Bath.
X.NURSING CARE PLAN
26
Name of Patient: Patient N.Y. Age: 17 years old Sex: Female Status: Single
Medical Diagnosis:
Name of Drug Route, Dosage, and Frequency
Mechanism of Action Indication Contraindication Adverse Reactions Nursing Interventions
Generic Name:
Omeprazole (Omepron)
Brand Name:
Losec, Prilosec, Prilosec OTC,Zegerid
Classification:
Proton Pump Inhibitor
20 mg capsule,Given Per Orem,OD
An antisecretory compound that is a gastric acid pump inhibitor.
It suppresses gastric acid secretion by inhibiting the H+, K+ ATPase enzyme system [the acid (proton H+) pump] in the parietal cells.
Duodenal and Gastric Ulcer.
Gastroesophageal reflux disease including severe erosive esophagitis (4-8 wk treatment).
Long term treatment of pathologic hypersecretory conditions such as Zollinger-Ellison syndrome, multiple endocrine adenomas, and systemic mastocytosis.
In combination with clarithromycin to treat duodenal ulcers associated with Helicobacter pylori.
Long term use for Gastroesophageal reflux disease (GERD).
Duodenal ulcers
PPI hypersensitivity in children <2 yrs. Old
OTC formulation in children <18 yrs. Old or bleeding.
Use of Zegerid in metabolic alkalosis, hypocalcemia, vomiting, and GI bleeding.
CNS: Headache Dizziness Fatigue
GI: Diarrhea Abdominal
pain Nausea Mild Transient
increase in Liver function tests.
UROGENITAL: Hematuria Proteinuria
SKIN: Rash
Laboratory Test: Monitor Urinalysis for Hematuria and Proteinuria.
Report for any changes in urinary elimination such as pain, discomfort associated with urination.
Monitor vital signs.
Report if diarrhea is present.
XII. DRUG STUDY
27
Name of Patient: Age: Sex: Status:Medical Diagnosis:
Name of Drug Route, Dosage, and Frequency
Mechanism of Action Indication Contraindication Adverse Reactions Nursing Interventions
Generic Name:
Ambroxol
Brand name:
Classification:
Muculytic
75 mg. tabletGiven Per OremOD
Adjuvant
therapy inpatients withabnormal, viscid, orinspissated mucoussecretions in acuteand chronicbronchopulmonarydiseases, and inpulmonarycomplications ofcystic fibrosis andsurgery,tracheostomy, andatelectasis.
There is no absolutecontraindication but inpatients with gastriculceration relativecaution should beobserved.
Occasionalgastrointestinalside effects mayoccur but theseare almostinvariably mild.
Monitor for Vital signs
Monitor for signs and symptoms.
XI.DRUG STUDY
28
Name of Patient: Age: Sex: Status:Medical Diagnosis:
Medications Exercise Treatment Hygiene Outpatient Diet
A. Omeprazole (Omepron)Proton Pump Inhibitor20 mg capsule, Given Per Orem, OD (8 am)
An antisecretory compound that is a gastric acid pump inhibitor.
B. Ambroxol Muculytic 75 mg. tablet given per Orem OD (8am).
Active and Passive ROM
- For venous return- To stimulate both
upper and lower extremities.
Ambulation- To prevent pain
from joints as a effect of not ambulation.
IVF Therapy- To replace the
fluids and electrolytes in our body.
Laboratories:a. CBC (Complete
Blood Count)b. Urinalysis
Oral care- These can prevent
microbes to accumulate in the mouth.
Changing of Clothes
Changing of napkin pads every 2-3 hours.
- For hygienic purposes and to monitor the pads and the blood that are
Environmental sanitation
- Promote healthy individual.
- Prevent illness that bought by
Proper Hand washing
On DAT (DIET AS TOLERETAD)
- Any foods can be given without any restrictions
Increase fluid intake
Increase in iron intake.
XIII. HEALTH TEACHING PLAN
29
REFERENCES:
Doenges, M., et al.Nursing Care Plans Guidelines for individualizing Patient care 6th ed.
(2002).Davis Company.Thailand.
Daniels, R., et al.Contemporary Medical-Surgical Nursing Thomson Asian Ed.(2007).
Delmar Learning.Asia.
Stedman’s Medical Dictionary. 27th edition.
Sanders.Scanlon.Essentials of Anatomy and Physiology.(2007). F.A. Davis Company.
Taiwsn.
Patient’s chart.
Client herself.
Prentice hall. Nurse’s Drug Guide.(2007). Pearson Education Inc. New Jersey.
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